Introduction

Should only be undertaken in stable relationships where the couple is certain they do not want any more children

Epidemiology

Rates falling in developed countries
UK is unusual as the number of men receiving the operation is greater than the number of women

18% of men between 18-69 have had a vasectomy

Only 64% of these were done on the NHS

95% of female sterilisations are performed on the NHS

Consent

It is unlikely that anyone with the following situation will be sterilised:

Under 30

No children

Not in a long-term relationship

Counselling is usually given to all parties. It is not necessary to have the partners permission, but it the patient is encouraged to involve them in the decision making process.

Reversal

Is possible, but is less likely the longer the patients has been sterilised. It not usually available on the NHS.

The procedure should be treated as irreversible – and discussed as such with the patient. For example, you should point out that if unseen circumstanced were to occur, whereby their current children were to become ill or die, they would be unable to have further children. Instances where couples are likely to express regret:

Failure

Like all surgery, there is a small proportion of operations that fail.

Choosing – vasectomy or female sterilisation

Vasectomy is:

30x less likely to fail

20x less likely to result in complications

Less invasive

Performed under local anaesthetic, and thus is a more minor procedure. Usually a day case.

Threat of pregnancy to the mother

Some diseases pose a risk to the mother’s life if she were to become pregnant, for example Primary pulmonary hypertension. In this condition, pregnancy could be fatal, and hormonal contraceptives may be contra-indicated. It would be in the woman’s best interest to be sterilised.

It is not a good idea to perform vasectomy on the partner in these instances, as it could be possible that the man would be widowed, and left infertile.

Female sterilisation

Tubal occlusion / Tubal ligation / Salpingectomy

Efficacy

Efficacy rates vary from 99.2 – 99.5%. The Filshie clip is thought to be the most effective.

It can be done laparoscopically (usually local anaesthetic) or as open surgery (general anaesthetic).

Procedure

Usually carried out at the isthsmus (the bit next to the uterus)

The ovaries and uterus are left intact

Ovulation may still occur, but the ovum is absorbed by surrounding tissues

May be laparotomy or laparoscopy.

Salpingectomy – is a particular procedure where the tubes are cut, and then sutured over.

Clips –some surgeons prefer to clip, rather than suture the tubes. The clip inhibits blood flow to the clipped area, and the region typically undergoes fibrosis and scarring which help to block the passage.

Rings –similar to a clip

Cauterization

Usually performed under general anaesthetic – however in some situations – e.g. directly after a caesarean, may be performed under local.

After Surgery

Women can consider themselves infertile straight after the procedure – but there is a risk of pregnancy in the menstrual cycle immediately prior to the surgery.

Complications

Laparoscopic surgery may need to be converted to open surgery if there are complications.

This is more likely in obese patients, and in those with previous abdominal surgery

Advise patients to seek urgent medical advice if they have vaginal bleeding, or abdominal pain, to rule out ectopic pregnancy

Associated with increased need for hysterectomy

Not associated with increased risk of heavy, irregular periods

Male sterilisation

Vasectomy

Efficacy

0.3% if there is:

Ligation of the vas, PLUS

Cauterisation of the ends, PLUS

Insertion of a fascia between the two ends

Around 1% if cauterisation only is used
Late failure occurs in 0.2% of cases

Surgical technique

The vas is palpated, and moved as close to the scrotal skin as possible. Local anaesthetic (lidocaine 1-2ml) is administered.

Through a small inscision in the scrotal skin, the vas is identified and clamped in two places, about 5cm apart

A small segment (e.g. 1cm) is removed and sent for histology to confirm it is actually the vas deferens.

Of the two ends, the testicular end is tied back on itself to reduce the risk of anastomosis, and the top end is also occluded, with non-absorbable stitching.

Some surgeons may insert an artificial fascia between the two ends to further reduce the risk of anastomoses

Suture up the skin

Alternative methods

Cauterisation of the vas

Measuring success

There needs to be two negative sperm count samples 1 month apart, taken after a minimum of 20 ejaculations.

After surgery

Normal ejaculation and orgasm occur, however, there is no sperm in the ejaculate.

May be painful, and men advised to take several days off work, and not do anything too strenuous for 1 week

Related Articles

Dr Tom Leach MBChB DCH EMCert(ACEM) currently works as a GP Registrar and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009.
Read full bio